Cardiogenic Pulmonary Edema Patients Research Articles

Evaluation of HACOR scale as a predictor of non-invasive ventilation failure in acute cardiogenic pulmonary oedema patients: A prospective observational study

Background and importanceAcute cardiogenic pulmonary oedema (ACPO) is a common indication for non-invasive ventilation (NIV) in the emergency department (ED). HACOR score of >5 is used to predict NIV failure. The predictive ability of HACOR may be affected by altered physiological parameters in ACPO patients due to medications or comorbidities. ObjectivesTo validate the HACOR scale in predicting NIV failure among acute cardiogenic pulmonary oedema (ACPO) patients. Design, settings and participantsThis is a prospective, observational study of consecutive ACPO patients requiring NIV admitted to the ED. Outcome measure and analysisPrimary outcome was the ability of the HACOR score to predict NIV failure. Clinical, physiological, and HACOR score at baseline and at 1 h, 12 h and 24 h were analysed. Other potential predictors were assessed as secondary outcomes. Main resultsA total of 221 patients were included in the analysis. Fifty-four (24.4%) had NIV failure. Optimal HACOR score was >5 at 1 h after NIV initiation in predicting NIV failure (AUC 0.73, sensitivity 53.7%, specificity 83.2%). As part of the HACOR score, respiratory rate and heart rate were not found to be significant predictors. Other significant predictors of NIV failure in ACPO patients were acute coronary syndrome, acute kidney injury, presence of congestive heart failure as a comorbid, and the ROX index. ConclusionsThe HACOR scale measured at 1 h after NIV initiation predicts NIV failure among ACPO patients with acceptable accuracy. The cut-off level > 5 could be a useful clinical decision support tool in ACPO patient. However, clinicians should consider other factors such as the acute coronary and acute kidney diagnosis at presentation, presence of underlying congestive heart failure and the ROX index when clinically deciding on timely invasive mechanical ventilation.

Second-order grey-scale texture analysis of pleural ultrasound images to differentiate acute respiratory distress syndrome and cardiogenic pulmonary edema

Discriminating acute respiratory distress syndrome (ARDS) from acute cardiogenic pulmonary edema (CPE) may be challenging in critically ill patients. Aim of this study was to investigate if gray-level co-occurrence matrix (GLCM) analysis of lung ultrasound (LUS) images can differentiate ARDS from CPE. The study population consisted of critically ill patients admitted to intensive care unit (ICU) with acute respiratory failure and submitted to LUS and extravascular lung water monitoring, and of a healthy control group (HCG). A digital analysis of pleural line and subpleural space, based on the GLCM with second order statistical texture analysis, was tested. We prospectively evaluated 47 subjects: 16 with a clinical diagnosis of CPE, 8 of ARDS, and 23 healthy subjects. By comparing ARDS and CPE patients’ subgroups with HCG, the one-way ANOVA models found a statistical significance in 9 out of 11 GLCM textural features. Post-hoc pairwise comparisons found statistical significance within each matrix feature for ARDS vs. CPE and CPE vs. HCG (P ≤ 0.001 for all). For ARDS vs. HCG a statistical significance occurred only in two matrix features (correlation: P = 0.005; homogeneity: P = 0.048). The quantitative method proposed has shown high diagnostic accuracy in differentiating normal lung from ARDS or CPE, and good diagnostic accuracy in differentiating CPE and ARDS. Gray-level co-occurrence matrix analysis of LUS images has the potential to aid pulmonary edemas differential diagnosis.

Benefit and harm of intravenous vasodilators across the clinical profile spectrum in acute cardiogenic pulmonary oedema patients.

The absence of high quality, large-scale data that indicates definitive mortality benefits does not allow for firm conclusions on the role of intravenous vasodilators in acute heart failure. We aimed to investigate the associations between intravenous vasodilators and clinical outcomes in acute heart failure patients, with a specific focus on patient profiles and type of vasodilators. Data of 26,212 consecutive patients urgently hospitalised for a primary diagnosis of acute heart failure between 2009 and 2015 were extracted from a government-funded multicentre data registration system. Propensity scores were calculated with multiple imputations and 1:1 matching performed between patients with and without vasodilator use. The primary endpoint was inhospital mortality. On direct comparison of the vasodilator and non-vasodilator groups after propensity score matching, there were no significant differences in the inhospital mortality rates (7.5% vs. 8.8%, respectively; P=0.098) or length of intensive/cardiovascular care unit stay and hospital stay between the two groups. However, there was a substantial difference in baseline systolic blood pressure by vasodilator type; favourable impacts of vasodilator use on inhospital mortality were observed among patients who had higher systolic blood pressures and those who had no atrial fibrillation on admission. Furthermore, when compared to nitrates, the use of carperitide (natriuretic peptide agent) was significantly associated with worse outcomes, especially in patients with intermediate systolic blood pressures. In acute heart failure patients, vasodilator use was not universally associated with improved inhospital outcomes; rather, its effect depended on individual clinical presentation: patients with higher systolic blood pressure and no atrial fibrillation seemed to benefit maximally from vasodilators. UMIN-CTR identifier, UMIN000013128.

Noninvasive Ventilation in Acute Hypoxemic Nonhypercapnic Respiratory Failure: A Systematic Review and Meta-Analysis

To evaluate the effectiveness of noninvasive ventilation in patients with acute hypoxemic nonhypercapnic respiratory failure unrelated to exacerbation of chronic obstructive pulmonary disease and cardiogenic pulmonary edema. PubMed, EMBASE, Cochrane library, Web of Science, and bibliographies of articles were retrieved inception until June 2016. Randomized controlled trials comparing application of noninvasive ventilation with standard oxygen therapy in adults with acute hypoxemic nonhypercapnic respiratory failure were included. Chronic obstructive pulmonary disease exacerbation and cardiogenic pulmonary edema patients were excluded. The primary outcome was intubation rate; ICU mortality and hospital mortality were secondary outcomes. Demographic variables, noninvasive ventilation application, and outcomes were retrieved. Internal validity was assessed using the risk of bias tool. The strength of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation methodology. Eleven studies (1,480 patients) met the inclusion criteria and were analyzed by using a random effects model. Compared with standard oxygen therapy, the pooled effect showed that noninvasive ventilation significantly reduced intubation rate with a summary risk ratio of 0.59 (95% CI, 0.44-0.79; p = 0.0004). Furthermore, hospital mortality was also significantly reduced (risk ratio, 0.46; 95% CI, 0.24-0.87; p = 0.02). Subgroup meta-analysis showed that the application of bilevel positive support ventilation (bilevel positive airway pressure) was associated with a reduction in ICU mortality (p = 0.007). Helmet noninvasive ventilation could reduce hospital mortality (p = 0.0004), whereas face/nasal mask noninvasive ventilation could not. Noninvasive ventilation decreased endotracheal intubation rates and hospital mortality in acute hypoxemia nonhypercapnic respiratory failure excluding chronic obstructive pulmonary disease exacerbation and cardiogenic pulmonary edema patients. There is no sufficient scientific evidence to recommend bilevel positive airway pressure or helmet due to the limited number of trials available. Large rigorous randomized trials are needed to answer these questions definitely.

Increased plasma levels of heparin-binding protein in patients with acute respiratory distress syndrome

IntroductionHeparin-binding protein (HBP) is an antimicrobial protein stored in neutrophil granules and plays a role in endothelial permeability regulation. The aim was to assess the diagnostic and prognostic value of measuring HBP in patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS).MethodsPlasma HBP was collected from 78 patients with ALI/ARDS, 28 patients with cardiogenic pulmonary edema (CPE) and 20 healthy volunteers at enrollment. Levels of HBP were measured by ELISA.ResultsPatients with ALI/ARDS had significantly higher median levels of HBP compared with patients with CPE (17.15 (11.95 to 24.07) ng/ml vs. 9.50 (7.98 to 12.18) ng/ml, P <0.001) at enrollment. There was no significant difference between CPE patients and healthy subjects in terms of HBP value (P = 0.372). The HBP levels of nonsurvivors was significantly higher than that of survivors (23.90 (14.81 to 32.45) ng/ml vs. 16.01 (10.97 to 21.06) ng/ml, P = 0.012) and multivariate logistic regression showed HBP (odds ratio =1.52, P = 0.034) was the independent predictor for 30-day mortality in patients with ALI/ARDS.ConclusionsPlasma HBP levels of ALI/ARDS patients were significantly higher than that of CPE patients. HBP was a strong prognostic marker for short-term mortality in ALI/ARDS.

Noninvasive ventilation or continuous positive airway pressure in pulmonary edema patients with respiratory acidosis? Look at the bicarbonates

Dear Editor, We read with interest the article of Nouira et al. [1] comparing noninvasive pressure support ventilation (NIPSV) and continuous positive airway pressure (CPAP) in the treatment of acute cardiogenic pulmonary edema (CPE). In the post hoc analysis carried out in hypercapnic patients, the authors found that these subjects seem not to respond successfully to NIPSV more than CPAP. These data support those by Bellone et al. [2], who failed to demonstrate a difference in efficacy between NIPSV and CPAP in hypercapnic CPE patients. We agree with the explanation of these findings given by Nouira and coworkers, who considered the application of positive end-expiratory pressure (PEEP) more relevant in CPE patients than relief of inspiratory workload by pressure support. However, some concerns may arise about those patients with chronic pump failure who develop acute on chronic respiratory acidosis because of an episode of CPE. Early recognition of these patients could be based on both past medical history and increased values of bicarbonates on basal blood gas analysis. From a pathophysiological point of view, CPE patients with acute on chronic respiratory acidosis could benefit more from inspiratory support delivered by NIPSV rather than a single level of PEEP delivered by CPAP. To explore this hypothesis, we retrospectively analyzed 378 consecutive CPE patients treated with CPAP in the Emergency Department [3]. There were 194 (51%) hypercapnic patients (PaCO2 [45 mmHg), among whom three groups of subjects were identified: those with acute respiratory acidosis on admission before CPAP treatment (pH\7.35 with PaCO2 [45 mmHg and 22 \ HCO3 \ 26 mEq/L), group A; those with ‘‘definite’’ acute on chronic respiratory acidosis (pH\7.35 with PaCO2 [45 mmHg and HCO3 [ 30 mEq/ L), group B; and those with ‘‘intermediate’’ acute on chronic respiratory acidosis (pH\7.35 with PaCO2 [45 mmHg and 26 B HCO3 B 30 mEq/L), group C. The number of patients with chronic obstructive pulmonary diseases was significantly higher in group B in comparison with group A (11 patients, 65% versus 19 patients, 25%, respectively, p = 0.002). We found patients in group B to have worse clinical outcomes in comparison with group A, with a significantly higher rate of switch from CPAP to NIPSV (Table 1). Group C accounted for 30 patients, of whom none had treatment failure. The evaluation of which of NIPSV and CPAP is preferable for CPE patients with acute on chronic respiratory acidosis should be explored in future clinical trails. However, we should acknowledge that the percentage of these subjects among all CPE patients who need noninvasive ventilation could be low, around 10% or less [3]. Thus, our hypothesis that NIPSV would be superior to CPAP in CPE patients with acute on chronic respiratory acidosis needs to be explored in large randomized controlled trials (RCTs). In the meantime, interesting data could also come from secondary analysis of studies performed by Nouira et al. as well as the 3CPO trialists [1, 4].

Hematocrit level correlates with lungs resistivity in elderly patients with cardiogenic pulmonary edema

Regular monitoring of pulmonary congestion in car-diogenic pulmonary edema (CPE) patients is neces-sary for its adequate management via pharmaceuti-cal treatment. It is well known that the development of CPE is accompanied with an increase in hema-tocrit, plasma protein concentration and colloid os-motic pressure due to the decrease in the plasma volume. In the present study the mean left and right lung resistivity values taken pre- and post treatment with diuretics using a hybrid bio-impedance electri-cal impedance tomography system were correlate to the measured changes in hematocrit level. A marginal significant correlation was found between the abso-lute mean lung resistivity and hematocrit levels (Pearson’s correlation coefficient of R = 0.4, p-value = 0.057). When the change in the mean lung resistivity of a patient was plotted vs. the change in hematocrit readout, a significant linear correlation was found (R = 0.7, p-value = 0.02). These results support the validity of the resistivity measurements using bio-impedance system in monitoring changes of pulmonary edema in CPE patients.

Use of noninvasive ventilation on internal wards for elderly patients with limitations to respiratory care: a cohort study

The use of noninvasive positive pressure ventilation (NPPV) outside the intensive wards has been evaluated in patients with no limitation on life-sustaining support. Our aim was to evaluate its usefulness in general wards for patients with NPPV as the ceiling of ventilator care when admission to the intensive care unit (ICU) has been withheld. Noninvasive positive pressure ventilation was used in 44 patients with acute respiratory failure (ARF) and limitations to respiratory care- 22 with chronic obstructive pulmonary disease (COPD) exacerbations and 22 with acute cardiogenic pulmonary oedema (CPE). Survival at hospital discharge, and survival and readmission rate at 12 months were assessed. Sixty-three per cent of COPD and 55% of CPE patients survived hospital discharge; and 50% and 37% respectively, were alive after 1 year. The cause of the in-hospital mortality was related to the admission diagnosis in 88% of cases. Cancer in COPD patients [P = 0·040, odds ratio (OR) = 15, 95% CI = 1·14-198] and the completion of NPPV treatment in both diseases (P = 0·008, OR = 0·03, 95% CI = 0·00-0·39 for COPD and P = 0·010, OR = 0·04, 95% CI = 0·00-0·45 for CPE) were related to in-hospital mortality. Fifty-six per cent of COPD and 33% of CPE patients that survived hospital admission were readmitted. Our study suggests that the use of NPPV in general wards could be a safe and effective option, as a last choice treatment, in patients with NPPV as the ceiling of ventilator care when admission to ICU has been withheld.

Management of Acute Cardiogenic Pulmonary Edema

Acute cardiogenic pulmonary edema (CPE) is a pathology frequently seen in patients presenting to emergency departments (EDs) and can usually be attributed to preexisting cardiovascular disease. Heart failure alone accounts for more than 1 million hospital admissions annually and has one of the highest ED morbidity and mortality to date (). Historically, CPE has been managed by the treating clinician in a manner that is based largely on anecdotal evidence. Furosemide (Lasix), morphine, and nitroglycerin have historically been the baseline standard for drug therapy in CPE management. A lack of drastic improvement in the patient's condition over the course of the ED visit may reflect a management style that results in higher morbidity and mortality for CPE patients. Several recent articles provide evidence-based outcomes that suggest changing standard therapy along with the adjunctive use of other medications. These articles also describe treatment modalities that result in a marked improvement in the management of patients with CPE along with decreases in adverse outcomes and hospital length of stay. The goal of this article is to present a summary of the evidence regarding the management of CPE and discuss the implications for current practice.

Diagnostic and Prognostic Utility of Brain Natriuretic Peptide in Subjects Admitted to the ICU With Hypoxic Respiratory Failure Due to Noncardiogenic and Cardiogenic Pulmonary Edema

Brain natriuretic peptide (BNP) is useful in diagnosing congestive heart failure (CHF) in patients presenting in the emergency department with acute dyspnea. We prospectively tested the utility of BNP for discriminating ARDS vs cardiogenic pulmonary edema (CPE). We enrolled ICU patients with acute hypoxemic respiratory failure and bilateral pulmonary infiltrates who were undergoing right-heart catheterization (RHC) to aid in diagnosis. Patients with acute coronary syndrome, end-stage renal disease, recent coronary artery bypass graft surgery, or preexisting left ventricular ejection fraction </= 30% were excluded. BNP was measured at RHC. Two intensivists independently reviewed the records to determine the final diagnosis. Eighty patients were enrolled. Median BNP was 325 pg/mL (interquartile range [IQR], 82 to 767 pg/mL) in acute lung injury/ARDS patients, vs 1,260 pg/mL (IQR, 541 to 2,020 pg/mL) in CPE patients (p = 0.0001). The correlation between BNP and pulmonary capillary wedge pressure was modest (r = 0.27, p = 0.02). BNP offered good discriminatory performance for the final diagnosis (C-statistic, 0.80). At a cut point </= 200 pg/mL, BNP provided specificity of 91% for ARDS. At a cut point >/= 1,200 pg/mL, BNP had a specificity of 92% for CPE. Higher levels of BNP were associated with a decreased odds for ARDS (odds ratio, 0.4 per log increase; p = 0.007) after adjustment for age, history of CHF, and right atrial pressure. BNP was associated with in-hospital mortality (p = 0.03) irrespective of the final diagnosis and independent of APACHE (acute physiology and chronic health evaluation) II score. In ICU patients with hypoxemic respiratory failure, BNP appears useful in excluding CPE and identifying patients with a high probability of ARDS, and was associated with mortality in patients with both ARDS and CPE. Larger studies are necessary to validate these findings.

Hypoproteinemia as a marker of acute respiratory distress syndrome in critically ill patients with pulmonary edema

To assess the value of serum protein levels for differentiating permeability pulmonary edema in the course of acute respiratory distress syndrome (ARDS) from cardiogenic pulmonary edema (CPE). Observational cohort study in intensive care units of 720-bed university hospital. Twenty-four consecutive patients with clinical evidence of edema, 11 fulfilling the consensus definition of ARDS, 7 having sepsis, 5 with all ARDS consensus criteria and sepsis but a pulmonary capillary wedge pressure above 18 mmHg (mixed), and 8 with CPE. All patients except for one with CPE were mechanically ventilated. Radionuclide assessments of pulmonary microvascular protein (transferrin) permeability (pulmonary leak index, PLI) were carried out and serum protein levels determined at admission and for ARDS/mixed patients, at recovery, defined by a decrease in positive end-expiratory pressure to 0 cmH2O. At admission the PLI was higher in ARDS/mixed than in CPE patients. The total protein and transferrin levels were lower in the former. The area under the curve of the receiver operating characteristic for diagnosing ARDS (vs. CPE) was 0.98 for transferrin (cutoff value 1.5 g/l), 0.95 for total protein (cutoff value 59 g/l) and 0.80 for albumin (cutoff value 24 g/l) levels. In various clinical diagnostic groups the transferrin level approached the PLI in diagnostic value. At recovery the PLI had decreased and serum protein levels increased. The data suggest that hypoproteinemia is a marker of ARDS. This may partially reflect increased permeability in the lungs, systemically, or both.

Haemodynamic and respiratory mechanics in cardiogenic pulmonary oedema patients: a clinical bedside study

Objective: To examine whether there is any difference in respiratory mechanics in patients with cardiogenic pulmonary oedema with and without shock. Design: Prospective observational study with follow-up to hospital discharge. Setting: A 17-bed medical and coronary intensive care unit in a 650-bed general hospital. Subjects: Thirty-eight adult patients mechanically ventilated for acute pulmonary oedema. Measurements and main results: Respiratory mechanics, including static inflation compliance of the total respiratory system, flow-dependent component inspiratory resistance, viscoelastic/volume redistribution inspiratory resistance component and intrinsic positive end-expiratory pressure were obtained immediately after tracheal intubation in every patient. A diagnosis of shock was established before tracheal intubation using clinical criteria. Eighteen patients had shock (Group I) and 20 did not (Group II). The overall population studied was characterised by low compliance (38.5±10.3 ml/cm H2O), high airway resistance (13.5±4.8 cmH2O/l/sec) and intrinsic positive end-expiratory pressure (6±3.2 cmH2O). However, those patients without shock had a higher airway resistance and intrinsic positive end-expiratory pressure than those with shock. Compliance of the total respiratory system was the same in both groups. Conclusions: In this study of patients with cardiogenic pulmonary oedema, compliance of the total respiratory system was the same among patients with and without shock; however airway resistance and intrinsic positive end-expiratory pressure were higher in those patients without shock.

Haemodynamic and respiratory mechanics in cardiogenic pulmonary oedema patients: a clinical bedside study

Objective: To examine whether there is any difference in respiratory mechanics in patients with cardiogenic pulmonary oedema with and without shock. Design: Prospective observational study with follow-up to hospital discharge. Setting: A 17-bed medical and coronary intensive care unit in a 650-bed general hospital. Subjects: Thirty-eight adult patients mechanically ventilated for acute pulmonary oedema. Measurements and main results: Respiratory mechanics, including static inflation compliance of the total respiratory system, flow-dependent component inspiratory resistance, viscoelastic/volume redistribution inspiratory resistance component and intrinsic positive end-expiratory pressure were obtained immediately after tracheal intubation in every patient. A diagnosis of shock was established before tracheal intubation using clinical criteria. Eighteen patients had shock (Group I) and 20 did not (Group II). The overall population studied was characterised by low compliance (38.5±10.3 ml/cm H2O), high airway resistance (13.5±4.8 cmH2O/l/sec) and intrinsic positive end-expiratory pressure (6±3.2 cmH2O). However, those patients without shock had a higher airway resistance and intrinsic positive end-expiratory pressure than those with shock. Compliance of the total respiratory system was the same in both groups. Conclusions: In this study of patients with cardiogenic pulmonary oedema, compliance of the total respiratory system was the same among patients with and without shock; however airway resistance and intrinsic positive end-expiratory pressure were higher in those patients without shock.